Elder Application Question Title * 1. Personal Information Name Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Email Address Phone Number Question Title * 2. Tribal Affiliation (type N/A if not applicable) Question Title * 3. Chapter House (if Navajo Nation Tribal Member) Question Title * 4. Age Question Title * 5. Birthdate Question Title * 6. Emergency Contact First Name Last Name Phone Number Relationship Question Title * 7. LGBTQIA Identity as a member of the LGBTQ community Does not identify as a member of the LGTBQ community Two-Spirit Unknown Question Title * 8. Gender Male Female Gender Fluid/Does Not Identify as Male or Female Question Title * 9. Ethnicity Hispanic or Latino Non-Hispanic or Non-Latino Question Title * 10. Racial Group Native American or Alaska Native African American/Black White/Caucasian Asian/Asian American Native Hawaiian or Other Pacific Islander Two or More Races Question Title * 11. Are you a U.S. Veteran? Yes No Question Title * 12. If yes, branch of service Question Title * 13. Are you an active member of the U.S. military? Yes No Question Title * 14. If yes, branch of service Question Title * 15. Do you have any family members actively serving in the military? Yes No Question Title * 16. Income level $24,999 or less $25,000 to $39,999 $40,000 to $59,999 $60,000 to $74,999 $75,000 to $99,999 $100,000 to 149,999 $150,000 or more Don’t know Question Title * 17. Housing Owned by mortgage or loan Owned by without mortgage or loan Rented Occupied without payment or rent Don’t know Question Title * 18. Availability Mornings Afternoons Evenings Monday Monday Mornings Monday Afternoons Monday Evenings Tuesday Tuesday Mornings Tuesday Afternoons Tuesday Evenings Wednesday Wednesday Mornings Wednesday Afternoons Wednesday Evenings Thursday Thursday Mornings Thursday Afternoons Thursday Evenings Friday Friday Mornings Friday Afternoons Friday Evenings Saturday Saturday Mornings Saturday Afternoons Saturday Evenings Sunday Sunday Mornings Sunday Afternoons Sunday Evenings Question Title * 19. How many mentorship hours are you able to accommodate per month? Question Title * 20. Why do you wish to be an Elder mentor? Question Title * 21. Do you have past experience working with youth? Yes No Question Title * 22. If yes, what was your role/experience? Question Title * 23. How would you rate your technology abilities? Little to no knowledge 2 3 4 Expert Question Title * 24. Do you have reliable transportation? Yes No Question Title * 25. If not, do you utilize public transportation? Yes No Question Title * 26. Describe any skills, education, accomplishments, spiritual knowledge/language that you possess Question Title * 27. Are there any health issues, mobility issues, and/or accommodations that Phoenix Indian Center staff need to be aware of? Question Title * 28. As an AmeriCorps Seniors volunteer, you will be covered by accident and personal liability insurance, and a small death benefit while performing volunteer duties. This coverage is automatic and free of cost to you as long as you are an active, enrolled member of AmeriCorps Seniors. Please provide the following info Beneficiary Name Relationship Beneficiary Phone Beneficiary Address City State Zip Question Title * 29. Are you willing to complete a fingerprint clearance and background check? Yes No Question Title * 30. How did you hear about this opportunity? Twitter Facebook Instagram Phoenix Indian Center website Family/Friends Flyers Other (please explain) Question Title * 31. Do you prefer to do your interview via Zoom or In-Person at the Phoenix Indian Center. Zoom In Person Question Title * 32. I understand that as an Elder Mentor, I will need to attend an orientation Yes No Question Title * 33. I understand that as an Elder mentor, I will need to complete required background checks and fingerprint clearance Yes No Question Title * 34. I understand that in my capacity as a Seniors Volunteer, I may come into contact with confidential information. I agree to protect this information to the best of my ability and not disclose it during or after my service as a volunteer had ended. Yes No Question Title * 35. I understand that if I use my personal automobile in my volunteer service, I will keep in effect automobile liability insurance equal or greater to the minimum requirement of the state of Arizona. I will also keep a valid Arizona State drivers’ license. Yes No Question Title * 36. Driver's License Information Driver's License State Expiration Date Question Title * 37. AmeriCorps Seniors provides mileage reimbursement to volunteers for travel between home and volunteer sites. Will you be claiming a mileage reimbursement for travel to and from your volunteer location? Yes No Question Title * 38. If yes, is a copy of your proof of auto insurance showing active coverage attached? Yes No Question Title * 39. Proof of auto insurance PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Proof of auto insurance Question Title * 40. I certify that the information completed in this application is correct to the best of my knowledge. Yes No Question Title * 41. Print Name Question Title * 42. Today's Date Date / Time Date Done
